Ongoing Needs Assessment Activities

Throughout the 2020-2021 grant year, we have continued to collect data and information to better understand Maternal and Child Health Block Grant (MCHBG) priority populations, including changes in disparities, and emerging and future needs. We are making progress toward improving our surveillance systems and data linkage across previously siloed systems, have identified specific research projects to better understand the needs of priority populations, have initiated ongoing needs assessment activities to collect feedback from priority populations and community leaders over the next four years, and are continuing to plan and develop dashboards and materials to better communicate public health findings to the public.

Our Title V activities include analyzing Pregnancy Risk Assessment Monitoring System (PRAMS) and birth certificate data to assess trends in behavior, access to care, and birth outcomes among the maternal/women’s and perinatal/infant health domains. The Perinatal Indicators Report for Washington state, including data through 2018, was published online in December 2020, and an updated summary of perinatal indicators through 2019 was prepared and presented to the Perinatal Advisory Committee in May 2021. Other improvements include continued development of data linkages between the Women, Infants and Children Nutrition Program (WIC) and birth certificate data; ongoing development of the birth defect surveillance and universal development screening data systems; and a successful grant proposal to link PRAMS data with the Washington Comprehensive Hospital Abstract Reporting System (CHARS). During the past year, additional topical fact sheets and materials were developed specific to maternal prenatal vitamin use, alcohol and tobacco use during pregnancy, access to prenatal care, preterm birth, low birth weight, and infant sleep position. Topical materials on well-child and adolescent medical visits, a common indicator of care among these youth populations, are currently in development for intended publication over the next year.

Beginning in January 2021, state Title V program leads and epidemiologists developed an ongoing qualitative collection model to help us better understand emergent needs, both in general and in relation to COVID-19. Specific questions include unmet needs, opportunities for improvement, community strengths, impacts of COVID-19, and trusted sources of health information. These questions have been incorporated into key stakeholder meetings, focus groups, and surveys in MCHBG-funded activities and related topical grant work within DOH. To date, these questions have been used in focus groups with the Birth Equity Project in Pierce County, children and youth with special health care needs (CYSHCN) stakeholder groups, and the Essentials for Childhood Steering Committee, which addresses childhood abuse, neglect, and protective factors throughout the state. This model of ongoing data collection will span multiple years and provide timely identification of emerging issues across racial/ethnic groups, ages, and geography.

Our Title V and Office of Family and Community Health Improvement (OFCHI) staff are exploring and developing new methods to bring data and information to our stakeholders in a more accessible and engaging way. For example, epidemiological staff are currently developing data dashboards on perinatal indicators, CYSHCN served by MCHBG funding, and state indicators on childhood risk and protective factors. We hope to create a dashboard soon for infant hearing screening data as well. A story sheet is currently in development, which will combine qualitative findings from the 2020 five-year maternal and child health needs assessment with data related to child access to care, including OFCHI’s well-child visit pilot project with managed care organizations (MCOs). Over the next year, we anticipate continued development in data presentation and reporting.

The 2020 Home Visiting Needs Assessment highlights persistent racial and ethnic disparities among families with young children, particularly among American Indian and Alaskan Native, Black or African American, Native Hawaiian or other Pacific Islander, and Hispanic populations. Findings were based on composite scores that included a range of indicators from four categories: socioeconomic status, maternal and child health, behavioral health, and education indicators. American Indian/Alaska Native populations were high risk or very high risk in all four categories, Black or African American populations were high risk or very high risk in all but behavioral health, and Native Hawaiian or other Pacific Islander and Hispanic populations were each high risk or very high risk in two of four domains. The report determined that the highest number of children ages 2 and younger in priority populations reside in Yakima, King, Pierce, Spokane, Snohomish, and Benton counties, with Black or African American populations specifically concentrated in urban areas. These findings were similar to those described in the Washington State Maternal Mortality Review Panel Report: 2014-2016. These include higher maternal mortality ratios for American Indian/Alaska Native mothers compared with all other racial/ethnic groups, and higher mortality rates among women covered by Medicaid, often used as a proxy measure of low socioeconomic status.

Changes in Health Status and Needs Among MCH Populations

Cross-cutting Overall Population Health

Access to care was a concern identified by all populations in the 2020 needs assessment, along with the cost of living, housing, and food security. Concerns about disparities by race and ethnicity, income, and geography were identified throughout the needs assessment.

An estimated 15 percent of all Washingtonians, and 19 percent of those under 18 years old, lived in poverty (<125 percent federal poverty level [FPL]) between 2014 and 2018. This was unevenly distributed around the state: County-specific estimates range from 11 to 33 percent, with rural counties having higher rates. There were significant racial and ethnic disparities, with an estimated 30 percent of Black or African American, 27 percent of American Indian/Alaska Native, 24 percent of Native Hawaiian or other Pacific Islander, 21 percent of Hispanic, 12 percent of Asian, and 8 percent of white residents living in poverty. (American Community Survey, 5-year rolling average 2014-2018)

In 2019, 16 percent of adults in Washington reported poor or fair physical health, compared with 18 percent in the U.S. This was highest among American Indian/Alaska Native (31 percent) and lowest among Asian (11 percent) populations. One-fourth of all adults (25 percent) reported diagnosed depression, higher than the national prevalence of 20 percent and slightly higher than in 2014 (22 percent). This was highest among American Indian/Alaska Native (35 percent), multiracial (34 percent), Black or African American (27 percent) and white (26 percent) populations. Seventy-one percent of adults had a medical check-up in the past year (compared with 78 percent nationally), with Hispanic respondents reporting significantly lower rate (65 percent) and white respondents reporting a higher rate (73 percent). Twelve percent delayed medical care due to cost, with Hispanic adults (21 percent) being the most impacted group. (Behavioral Risk Factor Surveillance System [BRFSS])

Maternal and Child Health Populations

The Overview section at the beginning of each report in the State Action Plan Narrative by Domain includes data and discussion of the health status of each of the MCH population domains.

Impacts of COVID-19 Pandemic

While DOH is working to better understand the impacts of COVID-19 among children, early indications suggest that access to care has decreased during 2020. Among 3- to 4-year-olds covered by Medicaid, preliminary reports indicate that only 54 percent received adequate well-child visits in 2020. This is compared with 67 percent in 2019 and 66 percent in 2018.

For adolescents, among 12- to 21-year-olds covered by Medicaid, only 28 percent received well visits in 2020. This is compared with 43 percent in 2019 and 40 percent in 2018 (MCO). In fall of 2020, Washington administered the COVID-19 Student Survey (CSS) in order to get a better understanding of how the lives of high school students were affected. Among the 30,000 students surveyed, 7 percent had received a positive COVID-19 diagnosis, and 16 percent had at least one diagnosis in their household. Around 30 percent of students reported not having received regularly scheduled medical care since the beginning of the 2020 school year. While 22 percent were worried about getting sick themselves, almost half (48 percent) were worried about friends and family members getting sick, and more than half (54 percent) were worried about falling behind in school. More than two-thirds (69 percent) reported that school felt more challenging during the pandemic, with 41 percent reporting lower grades compared with 27 percent reporting higher grades. Fifty-eight percent of responding students felt depressed or sad most days, 17 percent considered suicide, and 4 percent reported attempting suicide in the past 12 months. Unmet mental health needs and resources for adolescents were a known concern prior to the pandemic, and CSS results confirm this: only 23 percent of students sought mental health services in the past year, and of those, 69 percent were successful in receiving services.

The Community Recovery-Oriented Needs Assessment (CORONA) survey, which explored the behavioral, economic, social, and emotional impacts of COVID-19 on Washington residents, found that 43 percent of pregnant respondents and 42 percent of all women ages 18 to 44 were not able to see a doctor when they wanted to after February 2020 due to COVID-19. Respondents also indicated reduced access to medication, with 13 percent of pregnant respondents and 13 percent of women ages 18 to 44 reporting an inability to access medicine due to COVID-19. Among households with children, 57 percent reported that children experienced more difficulties with emotions, concentration, behavior, or getting along with others.

Parents participating in 2020 Birth Equity Project focus groups in Pierce County also cited teen mental health, depression, anxiety, and loneliness as top needs within the Native Hawaiian or other Pacific Islander and Black or African American community. According to one parent:

[It is] more difficult than ever to figure out what we can do. [My] child started at a new school and left [their] friends, how [are they] to meet new people in a new school? [They are] feeling left out.

We will continue exploring the impacts of the COVID-19 pandemic on the mental and behavioral health of adolescents, as well as the impact on systems of care for adolescents.

Working Toward a Better Understanding of MCH Needs

We are continuing development of the CHIF data system so we are better able to capture and use data related to CYSHCN in the state, with the intention of using that data to influence and improve services. We are developing a UDS data system, improving our Birth Defects Surveillance System, and making progress toward increasing data linkage across previously siloed systems.

We plan to focus on development of data dashboards, story sheets, and other material that will help us better communicate public health findings to our stakeholders and the public. We are being proactive in our data collection, particularly among hard-to-reach populations, to inform ongoing decision-making and the next needs assessment. We are engaging in trainings and discussions about how to increase awareness and inclusion of voices and opinions from marginalized communities, including communities of color, to influence our work and priorities.